During a four-year period, we saw 23 cases of child abuse with central nervous system involvement. Of these, five died and four were left with a substantial neurologic deficit as a result of injury. Of the 18 survivors, eight (44%) were removed from their home along with their siblings, one was placed in a sheltered environment with its mother, and nine (50%) were kept under surveillance. Six of the 12 patients with CT evidence of intracranial damage had no or minimal evidence of external cranial trauma. Although shaking as the major etiologic factor in neurologic impairment from child abuse has recently been questioned, our results implicate it as a common mechanism of injury. Every patient had a parent or guardian whose account of the mechanism of injury either changed from moment to moment or was inconsistent with the child's injury. Nine patients (39%) were known to have been seen previously by other physicians because of similar problems or other injuries consistent with child abuse. Early recognition of child abuse is paramount to saving not only the life of the affected child, but possibly the lives of siblings. Neurosurgeons should maintain a high index of suspicion for the diagnosis of child abuse.